Which surgeon should be consulted first for a patient with a sacral pressure ulcer complicated by sacral osteomyelitis?

Plastic Surgery Referral for Sacral Osteomyelitis from Pressure Ulcers

Refer patients with sacral pressure ulcers complicated by osteomyelitis to plastic surgery for definitive surgical management, as this specialty performs the bone debridement and musculocutaneous flap reconstruction required for durable wound closure. 1

Why Plastic Surgery is the Primary Surgical Specialty

The management of sacral osteomyelitis from pressure ulcers requires both aggressive bone debridement and complex flap reconstruction—procedures that fall squarely within plastic surgery's scope of practice. 1

Surgical debridement and flap coverage are indicated in patients with nonhealing stage IV pressure injuries to achieve rapid and durable closure of the soft tissue defect, resulting in reduced pain, reduced risk of recurrent local and systemic infections, and overall improvement in quality of life and functional capacity. 1

The specific procedures performed include:

• Irrigation and debridement of infected bone down to healthy bleeding tissue 1
• Musculocutaneous rotational flap reconstruction (such as inferior gluteal flaps for sacral wounds) to provide vascularized tissue coverage over the debrided bone 1
• Management of complex anatomical considerations unique to sacral osteomyelitis 1

Critical Anatomical Expertise Required

Plastic surgeons managing sacral osteomyelitis must navigate several high-risk anatomical structures that make this surgery particularly specialized:

• The dural tube terminates at the S2/S3 junction (approximately 0.38 cm distal to the posterior superior iliac spine), and inadvertent cerebrospinal fluid leakage during debridement can lead to meningitis 1, 2
• The lower sacral nerve roots (S2-S4) innervate urinary and anal sphincters, requiring careful preservation in non-paraplegic patients to avoid incontinence 1
• Sacral osteomyelitis most commonly affects the lower sacral segments below S3/S4, where bone is subcutaneous with poor intrinsic blood supply 1

Multidisciplinary Coordination

While plastic surgery performs the definitive procedure, optimal outcomes require coordination with other specialties:

• General surgery consultation may be needed for diverting colostomy in patients with fecal incontinence to prevent repetitive wound contamination, particularly in paraplegic patients 1
• Infectious disease consultation guides perioperative antibiotic selection and postoperative duration (typically 6 weeks following flap reconstruction) 1
• Orthopedic surgery involvement is occasionally reported in the literature for pelvic osteomyelitis management, but plastic surgery remains the primary specialty for sacral pressure ulcer reconstruction 3

Surgical Timing Considerations

Two approaches exist, though evidence is limited:

• One-stage approach: Bone debridement and flap coverage performed in a single episode or within 48 hours 1
• Two-stage approach: Initial debridement followed by negative pressure wound therapy for 5-10 weeks, then delayed flap reconstruction 1, 4

The lack of correlation between debridement-to-reconstruction interval and outcomes argues for shorter sequences to limit total antibiotic duration and healthcare resource utilization. 4

Common Pitfalls to Avoid

• Do not refer to orthopedic surgery as the primary service unless dealing with trochanteric osteomyelitis requiring femoral head resection (Girdlestone procedure), which is specific to paraplegic patients 1
• Avoid bilateral aggressive ischial debridement, as this transfers sitting pressure to the sacrum and poses high risk of central skin breakdown 1
• Ensure patient optimization before surgery: nutritional status, glycemic control, smoking cessation, and addressing psychosocial barriers are critical for surgical success 1